Business Process Automation In A Health Plan Organization

ABSTRACT

The computer implemented method and system disclosed herein automates business processes of a health plan organization using a plurality of portals. The portals comprise a sales portal, a member portal, an employer portal, an administration portal, and a provider portal. Health plans are listed using the sales portal. A sales agent proposes at least one of the health plans to a consumer using the sales portal. The administration portal generates insurance quotes for the proposed health plans. The consumer enrolls for the proposed health plans using one of the member portal and the employer portal. The consumer is billed for the enrolled health plans based on the insurance quotes using the administration portal. The consumer pays a premium amount online for the enrolled health plans using the member portal or the employer portal. The administration portal then generates commissions for the sales agent for the enrolled health plans.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No.11/901,526, titled “Business Process Automation in A Health PlanOrganization”, filed on Sep. 18, 2007 in the United States Patent andTrademark Office.

BACKGROUND

This invention, in general, relates to a health plan organization. Moreparticularly, this invention relates to automating business processes ofthe health plan organization.

Health plan organizations provide health care and health insurancecoverage to a consumer. There are various business processes involved inthe functioning of a health plan organization. These business processesinvolve many interactions between the departments of the health planorganization. The departments within a health plan organization mayinclude, but not limited to, a marketing department, a sales department,a finance department, an underwriting department, and a customerservices department. The business processes of each of these departmentsrequire manual intervention by brokers, sales representatives,underwriters, administrators, and customer service representatives. Theactivities of the departments including generating health plan proposalsand insurance quotes, enrolling consumers for various health plans,underwriting, tracking of payments etc., would therefore be timeconsuming and may lead to inefficiency of the business processes.Therefore, there is a need for increasing efficiency of the businessprocesses of the health plan organization and also integrating thebusiness processes within the health plan organization in order toimprove the quality of the health plans.

Moreover, the business processes in the health plan organization need toadhere to certain compliancy standards defined by the Health InsurancePortability and Accountability Act (HIPAA). These compliancy standardsensure privacy of consumer health information, secure electronictransactions, and simplified administration of the various businessprocesses in the health plan organization. The HIPAA requires compliancyof standards for transactions such as enrollment, eligibility or benefitinquiries, referral certification and authorization, payment ofpremiums, etc.

Hence, there is a need for a computer implemented method and system forautomating the business processes in a health plan organization andimproving the efficiency of transactions between various departments ofa health plan organization to improve the quality of the heath plans.

SUMMARY OF THE INVENTION

The computer implemented method and system disclosed herein addressesthe need for automating business processes of a health planorganization. The above stated need is addressed by providing aplurality of portals for automating the business processes of the healthplan organization.

The plurality of portals provided by the computer implemented method andsystem disclosed herein comprises a sales portal, a member portal, anemployer portal, an administration portal, and a provider portal. Asales agent registers with the health plan organization using the salesportal. The sales agent may be a broker or an individual authorized bythe health plan organization to sell the health plans. Theadministration portal authorizes the sales agent to access the salesportal. A plurality of health plans is then listed using the salesportal. The plurality of health plans comprises commercial health plans,dental plans, life insurance, vision insurance, long term disabilityinsurance plans, short term disability insurance plans, Medicare healthplans, and Medicaid health plans. The sales agent proposes at least oneof the plurality of health plans to a consumer using the sales portal.The consumer may be one of a member and an employer. A member may be oneof an individual, an individual with a family, an individual eligiblefor Medicare, a beneficiary or a recipient of a government program suchas a special needs plan (SNP) or Medicaid, and a member of an employergroup. The employer provides health care benefits to a group of membersof a company through the health plans. The administration portalgenerates insurance quotes for the proposed health plans for theconsumer.

The consumer then enrolls for the proposed health plans using one of themember portal and the employer portal. The step of enrolling of theconsumer further comprises authorizing the consumer via an electroniccorrespondence compliant with Health Insurance Portability andAccountability Act (HIPAA) standards, using one of the sales portal, theemployer portal, and the member portal. A provider renders health careservices defined by the enrolled health plans to the consumer using theprovider portal. The provider may also view membership and status ofmembership of the consumer enrolled for the health plans and trackstatus of consumer claims using the provider portal. The administrationportal then bills the consumer for the enrolled health plans. The stepof billing the consumer includes generating invoices for the consumerbased on the insurance quotes. The consumer then pays a premium amountonline for the enrolled health plans using one of the member portal andthe employer portal. Furthermore, the administration portal generatescommissions for the sales agent for the enrolled health plans. Thecomputer implemented method and system disclosed herein also comprisesrenewing the health plans and the insurance quotes for the consumerusing the administration portal. The consumer may also request foreffective changes to the enrolled health plans, consumer demographics,and constituents using one of the member portal and the employer portal.

The computer implemented method and system disclosed herein ensuresincreased efficiency of the business processes involved in the healthplan organization by integrating the plurality of departments of thehealth plan organization using the plurality of portals. The disclosedmethod and system also adheres to the compliancy standards defined bythe HIPAA, thereby improving the quality of the health plans.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing summary, as well as the following detailed description ofthe embodiments, is better understood when read in conjunction with theappended drawings. For the purpose of illustrating the invention,exemplary constructions of the invention are shown in the drawings.However, the invention is not limited to the specific methods andinstrumentalities disclosed herein.

FIG. 1 illustrates a method of automating business processes of a healthplan organization.

FIG. 2 illustrates a system for automating business processes of ahealth plan organization.

FIG. 3 exemplarily illustrates the interaction of various businessprocesses using the plurality of portals in a health plan organization.

DETAILED DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a method of automating business processes of a healthplan organization. The computer implemented method disclosed hereinprovides 101 a plurality of portals. The plurality of portals comprisesa sales portal 201, a member portal 202, an employer portal 203, anadministration portal 204, and a provider portal 205. A sales agentregisters with the health plan organization using the sales portal 201.The administration portal 204 authorizes the sales agent to access thesales portal 201. The sales agent maybe a broker or an individualauthorized by the health plan organization to sell the health plans. Theregistered sales agent is authorized via an electronic correspondencecompliant with predefined standards. The predefined standards arecharacterized by compliancy standards defined by the Health InsurancePortability and Accountability Act (HIPAA). The HIPAA protects healthinsurance coverage for a consumer. The HIPAA also determines theavailability of health insurance plans for the consumer. The consumermay be one of a member and an employer. A member may be one of anindividual, an individual with a family, an individual eligible forMedicare, a beneficiary or a recipient of a government program such as aspecial needs plan (SNP) or Medicaid, and a member of an employer group.The employer provides health care benefits to a group of members of acompany through the health plans. Health care benefits may also beprovided to members of the group even after termination of theiremployment. The registered sales agent receives an HIPAA compliantelectronic mail (email) with a username and a password. The username andpassword combination provided to the registered sales agent authorizesthe sales agent to access the sales portal 201, thereby ensuringsecurity and privacy of information of the sales agent.

A plurality of health plans is listed 102 using the sales portal 201.The plurality of health plans comprises commercial health plans,Medicare health plans, Medicaid health plans, and other health plansincluding dental plans, life insurance, vision insurance, long termdisability insurance plans, short term disability insurance plans, etc.Commercial health plans typically provide health care to consumersincluding members and employers. The employer provides health carebenefits to a group of members of a company through the health plans.Medicare health plans may cover consumers of ages sixty-five years andabove. Medicare health plans include hospital insurance and medicalinsurance. Hospital insurance may cover expenses of hospital stays ofthe consumer, whereas medical insurance covers outpatient requirements.Medicaid health plans provide medical coverage for consumers with lowincomes and resources. The consumers covered by Medicaid health plansmay include low-income parents, children, seniors, and consumers withdisabilities.

The sales agent captures information of the consumer in order to propose103 at least one of the plurality of health plans to the consumer usingthe sales portal 201. The captured consumer information comprisescontact information, medical history details, and insurance historydetails of the consumer. The consumer information is provided by theconsumer using one of the member portal 202 and the employer portal 203.For example, the sales agent proposes certain health plans coveringillnesses to consumers requiring more intensive care managementactivities, such as consumers with asthma, diabetes, rare healthconditions, or also consumers with specific unhealthy conditions orbehaviors, such as obesity, smoking and sedentary lifestyles. The salesagent proposes the health plans to the consumer based on the capturedconsumer information. The sales agent may propose the health plans tothe consumer via email using the sales portal 201.

Insurance quotes are then generated 104 for the health plans proposed bythe sales agent using the administration portal 204. The step ofgenerating the insurance quotes comprises evaluating health risks andhealth exposures of the consumer. The evaluation of risks is managed bythe administration portal 204 using an underwriting module 204 b. Anunderwriter analyzes the various factors to determine high and lowinsurance risks. The level of risks determines the quotations of theinsurance premiums. The sales portal 201 then lists the insurance quotesfor the proposed health plans for the consumer generated by theadministration portal 204.

The consumer, namely a member or an employer may then enroll 105 for atleast one of the proposed health plans using one of the member portal202 and the employer portal 203 respectively. The member portal 202 isused by the member to enroll for the proposed health plans, whereas theemployer portal 203 is used by the employer to enroll the group ofmembers of a company for the proposed health plans. The step ofenrolling of the consumer using one of the member portal 202 and theemployer portal 203 comprises authorizing the consumer via an electroniccorrespondence compliant with predefined standards. The consumer mayselect a primary care physician (PCP) associated with the health planorganization using one of the member portal 202 and the employer portal203. The consumer may also select the PCP for the consumer's familyusing one of the member portal 202 and the employer portal 203. Thepredefined standards are characterized by compliancy standards definedby the HIPAA. The consumer receives an HIPAA compliant electronic mailwith a username and a password from the administration portal 204. Theusername and password combination provided to the consumer authorizesthe consumer to access one of the member portal 202 and the employerportal 203, thereby ensuring security and privacy of information of theconsumer. The consumer may compare the proposed health plans with thelisted health plans for assessing benefits of the health plans proposedby the sales agent. The consumer enrolls for the health plans bycomparing the insurance quotes of the proposed health plans. Theemployer verifies whether the group of members has enrolled for theproposed health plans.

A provider renders health care services defined by the enrolled healthplans to the consumer using a provider portal 205. The provider ofhealth care may be one of a primary care physician, a hospital network,or a medical lab network. When a particular provider is selected by theconsumer as the PCP, the provider is kept informed through the providerportal 205. The health benefits of the consumer are also determinedthrough the provider portal 205 based on the enrolled health plans. Theprovider then renders health care services defined by the enrolledhealth plans and the health plan contract to the consumer. Theadministration portal 204 bills 106 the consumer for the enrolled healthplans based on the insurance quotes. A billing and commissions engine204 c of the administration portal 204 generates invoices for theconsumer based on the insurance quotes. The administration portal 204tracks the payment of the invoices by the consumer. The step of trackingthe payment comprises sending reminders to the consumer to make therequired payments. The consumer makes payments after receiving theinvoices by using one of the member portal 202 and the employer portal203. The consumer pays 107 a premium amount online for the enrolledhealth plans using one of the member portal 202 and the employer portal203. The payments may be made online using the member portal 202 andemployer portal 203 through one of credit cards, debit cards, electronicchecks, and other modes of electronic payment.

The administration portal 204 then generates 108 commissions for thesales agent using the billing and commissions engine 204 c, and sendsthe commission information to the sales portal 201 for viewing by thesales agent. Commissions are generated as remuneration for the healthplans sold by the sales agent. Commission payments may be made to thesales agent using an electronic deposit method. The health plans andinsurance quotes for a consumer may also be renewed using theadministration portal 204 and sent to the sales portal 201 via a network207. The administration portal 204 coordinates the business processes ofthe sales portal 201, the member portal 202, the employer portal 203,and the provider portal 205 via the network 207.

FIG. 2 illustrates a system for automating business processes of ahealth plan organization. The computer implemented system 200 disclosedherein comprises a plurality of portals. The plurality of portalscomprises a sales portal 201, a member portal 202, an employer portal203, an administration portal 204, and a provider portal 205. Aplurality of health plans such as commercial health plans, Medicarehealth plans, and Medicaid health plans are listed using the salesportal 201. The sales portal 201 comprises a sales agent registrationmodule 201 a and a health plan selection module 201 b. The sales agentregistration module 201 a enables the registration of the sales agentwith the health plan organization. The administration portal 204authorizes the registered sales agent via an electronic correspondencecompliant with predefined standards using an authorization engine 204 a.The predefined standards are characterized by compliancy standardsdefined by the HIPAA as explained in the detailed description of FIG. 1.The registered sales agent receives an HIPAA compliant electronic mailwith a username and a password. The username and password combinationprovided to the registered sales agent authorizes the sales agent toaccess the sales portal 201. The sales agent information comprisingsales agent identification, sales agent login details, and summary ofthe sales agent commissions is stored in a portal database 206.

The health plan selection module 201 b of the sales portal 201 enablesthe sales agent to select health plans for the consumer. The sales agentselects the health plans based on the information provided by theconsumer. The consumer information comprises contact information,medical history details, and insurance history details of the consumer.The consumer information is provided by the consumer using one of themember portal 202 and the employer portal 203. The consumer informationcomprising the login details of the consumer, contact information of theconsumer, medical history details of the consumer, a summary of theenrolled health plans, consumer identification number, consumer name,date of service, type of service, provider details, total billableservice details, amounts of service charges etc., is stored in theportal database 206. The health plans to be proposed to the consumer maybe compared across the list of health plans to determine the benefits ofthe proposed health plans. The sales agent then uses the health planselection module 201 b to propose at least one of the selected healthplans to the consumer. The administration portal 204 generates insurancequotes for the health plans proposed by the sales agent. Generatinginsurance quotes requires the evaluation of health risks and healthexposures of the consumer. The health plan selection module 201 b alsolists insurance quotes for the proposed health plans generated by theadministration portal 204. The administration portal 204 communicateswith the sales portal 201 via a network 207. The sales agent proposesthe health plans to the consumer via electronic mail (email) using thehealth plan selection module 201 b of the sales portal 201.

The member portal 202 of the computer implemented system 200 disclosedherein comprises a member enrollment and maintenance module 202 a and amember payment module 202 b. The administration portal 204 authorizes amember via an electronic correspondence compliant with predefinedstandards using the authorization engine 204 a. The predefined standardsare characterized by compliancy standards defined by the HIPAA. Themember receives an HIPAA compliant electronic mail with a username and apassword. The username and password combination provided to the memberauthorizes the member to access the member portal 202. Theadministration portal 204 communicates with the member portal 202 viathe network 207.

On receiving access to the member portal 202, the member may view thehealth plans and insurance quotes proposed by the sales agent. Themember portal 202 communicates with the sales portal 201 via the network207. The member may compare the proposed health plans with the list ofhealth plans for assessing the benefits of the proposed health plans.The member enrollment and maintenance module 202 a of the member portal202 is used for enrolling the member for at least one of the healthplans proposed by the broker. The member may select a primary carephysician (PCP) associated with the health plan organization using themember portal 202. The member may also select the PCP for the member'sfamily using the member portal 202. The member may also waive coverageof certain health plans depending on the needs of the member. Afterenrollment for at least one of the proposed health plans, the member mayrequest for identification cards and change member information includinglogin details, contact information etc., using the member enrollment andmaintenance module 202 a of the member portal 202. The memberinformation is stored in the portal database 206.

The member payment module 202 b of the member portal 202 enables themember to make payments for the enrolled health plans. The memberreceives invoices generated by a billing and commissions engine 204 c ofthe administration portal 204 via the network 207. The member pays apremium amount online for the enrolled health plans using the memberportal 202. The member makes payments for the enrolled health plansonline using the member payment module 202 b through one of creditcards, debit cards, electronic checks, and other modes of electronicpayment. The computer implemented system 200 disclosed herein alsocomprises a provider portal 205 used by a provider to render health careservices defined by the enrolled health plans to the consumer. Theprovider may be one of a primary care physician, a hospital network, anda medical lab network. The member may select a provider based on therequirements of the member through the member portal 202. Once theselection is made, the member information including the health benefitinformation is updated in a consumer information maintenance module 205a of the provider portal 205.

The employer portal 203 of the computer implemented system 200 disclosedherein comprises an employer enrollment and maintenance module 203 a, anemployer payment module 203 b, and a group roster management module 203c. The administration portal 204 authorizes the employer via anelectronic correspondence compliant with predefined standards using theauthorization engine 204 a. The predefined standards are characterizedby compliancy standards defined by the HIPAA. The employer receives anHIPAA compliant electronic mail with a username and a password. Theusername and password combination provided to the employer authorizesthe employer to access the employer portal 203. The administrationportal 204 communicates with the employer portal 203 via the network207. The employer of a company provides health care benefits to a groupof members of the company through the health plans. The group of membersmay be further divided into subgroups based on the number of members.For example, the group of members of the company may be divided intosmall groups of fifty members and large groups of fifty and abovemembers. The members of a company may also be grouped into activemembers, terminated members, etc. The information about the groups ofmembers is maintained using the group roster management module 203 c.

The employer uploads preliminary group census information or detailedgroup census information to the portal database 206 using the grouproster management module 203 c. The preliminary group census informationcontains mandatory group member details such as age, gender, applicabletier and zip code of location. The preliminary group census informationmay also comprise email addresses and Medicare eligibility of the group.The detailed group census information contains group member details suchas first name, last name, age, gender, applicable tier, zip code oflocation, date of birth, email address, and Medicare eligibility,wherein age, gender, applicable tier and zip code of location aremandatory details. The employer may either specify the member's age orprovide a date of birth. The employer may also designate a sales agentor a broker agency for each group of members. The employer may view,verify, and update group census information using the employer portal203. The employer may also select a primary care physician (PCP)associated with the health plan organization using the employer portal203. The employer may also select the PCP for the member's family usingthe employer portal 203.

The employer portal 203 enables the employer to view the health plansand insurance quotes proposed by the sales agent. The employer portal203 communicates with the sales portal 201 via the network 207. Theemployer may compare the proposed health plans with the list of healthplans for assessing the benefits of the proposed health plans for thegroup of members. The employer enrolls the group of members for at leastone of the health plans proposed by the sales agent using the employerenrollment and maintenance module 203 a of the employer portal 203. Theemployer may also waive coverage of certain health plans depending onthe needs of the group of members. After enrollment for at least one ofthe proposed health plans, the employer may request for identificationcards and change login details, contact information, and group censusinformation etc., using the employer enrollment and maintenance module203 a of the employer portal 203. The employer manages the details ofthe group members using the group roster management module 203 c of theemployer portal 203.

The employer payment module 203 b of the employer portal 203 enables theemployer to make payments for the enrolled health plans. The employerreceives invoices generated by a billing and commissions engine 204 c ofthe administration portal 204 via the network 207. The employer pays apremium amount online for the enrolled health plans using the employerportal 203. The employer makes payments for the enrolled health plansonline using the employer payment module 203 b through one of creditcards, debit cards, electronic checks, and other modes of electronicpayment. The computer implemented system 200 disclosed herein furthercomprises a provider portal 205 used by a provider to render health careservices defined by the enrolled health plans to the group of members ofthe company. The employer may select a provider based on therequirements of the group of members through the employer portal 203.

The provider portal 205 comprises a consumer information maintenancemodule 205 a for maintaining and managing information of the consumerassociated with the provider. The consumer information maintenancemodule 205 a also submits and tracks the status of provider claims, andviews the status of membership of the consumer. The consumer informationmaintenance module 205 a also informs the provider when any newconsumers select that provider as the PCP. The consumer's healthbenefits are determined and accessed through the consumer informationmaintenance module 205 a of the provider portal 205 based on the healthplans enrolled by the consumer and as proposed by the sales agent.

In one embodiment of the computer implemented system 200 disclosedherein, the members of the group may also be provided with health carebenefits after termination from employment of the company as defined bythe statutes of the Consolidated Omnibus Budget Reconciliation Act(COBRA). COBRA enables members of the group to maintain health insurancecoverage of the health plans after termination of employment. Thecomputer implemented system 200 disclosed herein manages healthinsurance coverage of terminated members of the group by generatingCOBRA letters for the terminated members of the group, and updating thestatus of the terminated members. The administration portal 204generates monthly coupons for the terminated members. The generatedCOBRA letters and coupons may be viewed by the employer using theemployer portal 203. The billing and commissions engine 204 c of theadministration portal 204 generates invoices for the terminated membersand tracks payment of the invoices via the network 207.

The administration portal 204 of the computer implemented system 200disclosed herein comprises an authorization engine 204 a, anunderwriting module 204 b, a billing and commissions engine 204 c, acustomer services module 204 d, an administrative and maintenanceactivity module 204 e, and a rating engine 204 f. The authorizationengine 204 a authorizes the sales agent, the member, and the employervia an electronic correspondence compliant with Health InsurancePortability and Accountability Act standards as explained in thedetailed description of FIG. 1. The authorization engine 204 aauthorizes the consumer with a unique set of username and password. Theauthorization engine 204 a authorizes the sales agent to access thesales portal 201, the member to access the member portal 202, and theemployer to access the employer portal 203. The authorization engine 204a of the administration portal 204 communicates with the sales portal201, the member portal 202, and the employer portal 203 via the network207.

The rating engine 204 f generates insurance quotes for the health plansproposed by the sales agent. The underwriting module 204 b of theadministration portal 204 further modifies the insurance quotesgenerated by the rating engine 204 f based on the evaluation of thehealth risks and health exposures of the consumer by an underwriter. Theunderwriting module 204 b determines debit points for pre-existingmedical conditions of the consumer. The underwriter approves or rejectsthe consumer for the health plans based on the debit points calculatedfor the consumer. The underwriting module 204 b then sends the generatedinsurance quotes to the sales portal 201 via the network 207. Theunderwriting module 204 b also renews the health plans and the insurancequotes for the consumer and sends the renewed health plans and insurancequotes to the sales portal 201 via the network 207.

The billing and commissions engine 204 c bills the consumer for theenrolled health plans based on the insurance quotes generated by thehealth plan selection module 201 b of the sales portal 201. The billingand commissions engine 204 c generates invoices for the consumer basedon the insurance quotes. In the case of an inclusion or a removal of amember in a group of a company, the billing and commissions engine 204 crecalculates the invoices and renews the invoices for the enrolledhealth plans. The billing and commissions engine 204 c also renewsinvoices for the consumer, in the case of payment deficits, overpayments by the consumer, and a change in the health plans. The renewedinvoices are sent to one of the member portal 202 and the employerportal 203 via the network 207. The invoices may be tracked for paymentby the consumer using the billing and commissions engine 204 c. Thebilling and commissions engine 204 c sends reminders to the consumer forthe payment. The billing details comprising the invoices, status ofpayment, billing cycle, and reminders for the payment are stored in theportal database 206.

The billing and commissions engine 204 c generates commissions for thesales agent based on the enrolled health plans. In the case of aninclusion or a removal of a member in a group of a company, the billingand commissions engine 204 c recalculates the commissions and renews thecommissions for the sales agent. The billing and commissions engine 204c generates commissions as remuneration for the health plans sold by thesales agent. The billing and commissions engine 204 c sends thecommissions information to the sales portal 201 via the network 207.Commission payments may be made to the sales agent using an electronicdeposit method.

The customer services module 204 d of the administration portal 204resolves service issues, complaints, grievances, and non medical appealsof the consumer. The customer services module 204 d communicates withthe sales portal 201, the member portal 202, the employer portal 203,the administration portal 204, and the provider portal 205 via thenetwork 207 using secured communication. Further, secured messagingability is provided between all the components of the computerimplemented system 200. The consumer may submit service issues,complaints or grievances online to the customer services module 204 dusing one of the member portal 202 and the employer portal 203. Further,the administration and maintenance activity module 204 e is used tomanage and control all other administrative and maintenance activitiesof the health plan organization.

Based on the health plans or insurance company policies and businessrules, the health plan organization allows employers to add or terminatemembers from the group roster within a certain number of days. Theemployer may add or terminate members from the group using the grouproster management module 203 c. The administration portal 204 allows thehealth plan organization to dynamically control the number of days byusing a configurable parameter represented by the alphabet “x”. Thehealth plan organization may change the configurable parameter “x” asthe health plan organization's policies change to allow the employer tomake roster changes retro-actively or for future dates. In some cases,the sales agent may act as the roster manager for a group afterreceiving authorization from the employer.

FIG. 3 exemplarily illustrates the interaction of various businessprocesses using the plurality of portals in a health plan organization.The administration portal 204 communicates and coordinates the salesportal 201, the member portal 202, the employer portal 203, and theprovider portal 205 used by a plurality of departments in the healthplan organization. The portals communicate with the administrationportal 204 via the network 207. For example, the administration portal204 authorizes the sales agent to access the sales portal 201. Aplurality of health plans is listed using the sales portal 201. Thehealth plans listed in the sales portal 201 include, but not limited to,commercial health plans, Medicare health plans, Medicaid health plansand other health plans including dental plans, life insurance, visioninsurance, long term disability insurance plans, short term disabilityinsurance plans, etc. The sales agent proposes at least one of theplurality of health plans to the consumer using the sales portal 201.Insurance quotes are generated for the proposed health plans using theadministration portal 204. The administration portal 204 may alter thegenerated insurance quotes based on the on the evaluation of the healthrisks and health exposures of the consumer by an underwriter. Thegenerated insurance quotes are then sent to the sales portal 201 fromthe administration portal 204 via the network 207. The administrationportal 204 authorizes the consumer to gain access to one of the memberportal 202 and the employer portal 203. The consumer enrolls for atleast one of the health plans proposed by the sales agent using one ofthe member portal 202 and the employer portal 203. The administrationportal 204 also coordinates the provision of health care servicesdefined by the enrolled health plans to the consumer by a provider usingthe provider portal 205 as illustrated in FIG. 3. The administrationportal 204 then bills the consumer for the enrolled health plans basedon the insurance quotes using a billing and commissions engine 204 c.The billing details comprising the invoices, status of payment, billingcycle, and reminders for the payment are stored in the portal database206. The consumer then pays a premium amount online for the enrolledhealth plans using one of the member portal 202 and the employer portal203. The administration portal 204 also generates commissions for thesales agent for the enrolled health plans. The commissions generated bythe administration portal 204 are then sent to the sales portal 201 forviewing by the sales agent.

It will be readily apparent that the various methods and algorithmsdescribed herein may be implemented in a computer readable mediumappropriately programmed for general purpose computers and computingdevices. Typically a processor, for e.g., one or more microprocessorswill receive instructions from a memory or like device, and executethose instructions, thereby performing one or more processes defined bythose instructions. Further, programs that implement such methods andalgorithms may be stored and transmitted using a variety of media, fore.g., computer readable media in a number of manners. In one embodiment,hard-wired circuitry or custom hardware may be used in place of, or incombination with, software instructions for implementation of theprocesses of various embodiments. Thus, embodiments are not limited toany specific combination of hardware and software. A ‘processor’ meansany one or more microprocessors, Central Processing Unit (CPU) devices,computing devices, microcontrollers, digital signal processors or likedevices. The term ‘computer-readable medium’ refers to any medium thatparticipates in providing data, for example instructions that may beread by a computer, a processor or a like device. Such a medium may takemany forms, including but not limited to, non-volatile media, volatilemedia, and transmission media. Non-volatile media include, for example,optical or magnetic disks and other persistent memory volatile mediainclude Dynamic Random Access Memory (DRAM), which typically constitutesthe main memory. Transmission media include coaxial cables, copper wireand fiber optics, including the wires that comprise a system bus coupledto the processor. Transmission media may include or convey acousticwaves, light waves and electromagnetic emissions, such as thosegenerated during Radio Frequency (RF) and Infrared (IR) datacommunications. Common forms of computer-readable media include, forexample, a floppy disk, a flexible disk, hard disk, magnetic tape, anyother magnetic medium, a Compact Disc-Read Only Memory (CD-ROM), DigitalVersatile Disc (DVD), any other optical medium, punch cards, paper tape,any other physical medium with patterns of holes, a Random Access Memory(RAM), a Programmable Read Only Memory (PROM), an Erasable ProgrammableRead Only Memory (EPROM), an Electrically Erasable Programmable ReadOnly Memory (EEPROM), a flash memory, any other memory chip orcartridge, a carrier wave as described hereinafter, or any other mediumfrom which a computer can read. In general, the computer-readableprograms may be implemented in any programming language. Some examplesof languages that can be used include C, C++, C#, or JAVA. The softwareprograms may be stored on or in one or more mediums as an object code. Acomputer program product comprising computer executable instructionsembodied in a computer-readable medium comprises computer parsable codesfor the implementation of the processes of various embodiments.

Where databases are described such as the portal database 206, it willbe understood by one of ordinary skill in the art that (i) alternativedatabase structures to those described may be readily employed, and (ii)other memory structures besides databases may be readily employed. Anyillustrations or descriptions of any sample databases presented hereinare illustrative arrangements for stored representations of information.Any number of other arrangements may be employed besides those suggestedby, e.g., tables illustrated in drawings or elsewhere. Similarly, anyillustrated entries of the databases represent exemplary informationonly; one of ordinary skill in the art will understand that the numberand content of the entries can be different from those described herein.Further, despite any depiction of the databases as tables, other formatsincluding relational databases, object-based models and/or distributeddatabases could be used to store and manipulate the data types describedherein. Likewise, object methods or behaviors of a database can be usedto implement various processes, such as the described herein. Inaddition, the databases may, in a known manner, be stored locally orremotely from a device that accesses data in such a database.

The present invention can be configured to work in a network environmentincluding a computer that is in communication, via a communicationsnetwork, with one or more devices. The computer may communicate with thedevices directly or indirectly, via a wired or wireless medium such asthe Internet, Local Area Network (LAN), Wide Area Network (WAN) orEthernet, Token Ring, or via any appropriate communications means orcombination of communications means. Each of the devices may comprisecomputers, such as those based on the Intel.®. processors, AMD.®.processors, UltraSPARC.®. processors, etc, that are adapted tocommunicate with the computer. Any number and type of machines may be incommunication with the computer.

The foregoing examples have been provided merely for the purpose ofexplanation and are in no way to be construed as limiting of the presentmethod and system disclosed herein. While the invention has beendescribed with reference to various embodiments, it is understood thatthe words, which have been used herein, are words of description andillustration, rather than words of limitation. Further, although theinvention has been described herein with reference to particular means,materials and embodiments, the invention is not intended to be limitedto the particulars disclosed herein; rather, the invention extends toall functionally equivalent structures, methods and uses, such as arewithin the scope of the appended claims. Those skilled in the art,having the benefit of the teachings of this specification, may effectnumerous modifications thereto and changes may be made without departingfrom the scope and spirit of the invention in its aspects.

1. A computer implemented system for automating business processes of ahealth plan organization, comprising: a plurality of portals comprising:a sales portal for listing a plurality of health plans and proposing atleast one of said plurality of health plans to a consumer by a salesagent, wherein said consumer is one of a member and an employer; amember portal comprising a member enrollment and maintenance module forenrolling for at least one of said proposed health plans by said member;an employer portal comprising an employer enrollment and maintenancemodule for enrolling for at least one of the proposed health plans bysaid employer, wherein the employer provides health care benefits to agroup of members of a company through the proposed health plans; aprovider portal for rendering health care services by a provider definedby said enrolled health plans to the consumer; an administration portalfor coordinating said business processes of said plurality of portals,comprising: a rating engine for generating insurance quotes for theproposed health plans; and a billing and commissions engine for billingthe consumer for the enrolled health plans based on said insurancequotes and for generating commissions for said sales agent for theenrolled health plans.
 2. The computer implemented system of claim 1further comprising a portal database for storing sales agentinformation, consumer information, group census information, billingdetails, and commissions information.
 3. The computer implemented systemof claim 2, wherein said sales agent information comprises sales agentidentification, sales agent login details, and summary of sales agentcommissions.
 4. The computer implemented system of claim 2, wherein saidconsumer information comprises login details of the consumer, contactinformation of the consumer, medical history details of the consumer, asummary of the enrolled health plans of the consumer, consumeridentification number, consumer name, date of service, type of service,provider details, total billable service details, and amounts of servicecharges.
 5. The computer implemented system of claim 2, wherein saidgroup census information comprises information obtained from a group ofmembers receiving health care benefits from the employer of a company.6. The computer implemented system of claim 2, wherein said billingdetails comprise invoices, status of payment, billing cycle, andreminders for said payment.
 7. The computer implemented system of claim1, wherein said sales portal further comprises a sales agentregistration module for registering the sales agent with said healthplan organization, wherein said registered sales agent is authorized viaan electronic correspondence compliant with Health Insurance Portabilityand Accountability Act standards.
 8. The computer implemented system ofclaim 1, wherein said sales portal further comprises a health planselection module for selecting said health plans, and proposing at leastone of said selected health plans to the consumer.
 9. The computerimplemented system of claim 1, wherein said administration portalfurther comprises an authorization engine for authorizing the member andthe employer to access said member portal and said employer portalrespectively.
 10. The computer implemented system of claim 1, whereinsaid administration portal further comprises a customer services modulefor resolving complaints, grievances, and non medical appeals of theconsumer.
 11. The computer implemented system of claim 1, wherein saidadministration portal further comprises a administration and maintenanceactivity module for managing and controlling the administrative andmaintenance activities of the health plan organization.
 12. The computerimplemented system of claim 1, wherein said administration portalfurther comprises an underwriting module for evaluating health risks andhealth exposures of the consumer.
 13. The computer implemented system ofclaim 12, wherein said underwriting module renews health plans and theinsurance quotes for the consumer.
 14. The computer implemented systemof claim 1, wherein said member portal further comprises a memberpayment module for making payments by the member for the enrolled healthplans.
 15. The computer implemented system of claim 1, wherein saidemployer portal further comprises an employer payment module for makingpayments by the employer for the enrolled health plans.
 16. The computerimplemented system of claim 1, wherein said employer portal furthercomprises a group roster management module for managing said group ofmembers of said company enrolled for said health plans by the employer.17. The computer implemented system of claim 1, wherein said billing andcommissions engine generates invoices for the consumer based on theinsurance quotes.
 18. The computer implemented system of claim 17,wherein the billing and commissions engine tracks payment of saidinvoices by the consumer and sends reminders to the consumer for saidpayment.
 19. The computer implemented system of claim 1, wherein saidprovider portal comprises a consumer information maintenance module formaintaining and managing information of the consumer associated withsaid provider, submitting and tracking the status of provider claims,and viewing status of membership of the consumer.